The Care Coordinator functions as a member of an interdisciplinary team to provide care coordination to a caseload of severely mentally ill adults with multiple medical co morbidities and/or co-occurring substance abuse disorders. Advocate for and support the client, engage with community agencies/health care providers and others on his/her behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations.

Responsibilities:

+ Provide clinical support to the Team by providing consultation, education information around conditions, interventions, resources to maintain focus on outcomes and best practices.

+ Conduct initial and ongoing assessments of clients to document strengths, needs, goals and resources.

+ Follow up with hospital care teams during admissions and discharges to facilitate discharge planning and arranging outpatient follow-up

+ Assist wit...